A0888, Noncovered ambulance mileage, per mile (e.g., for miles traveled beyond closest
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
0.00
Facility
N/A
Non-Facility
N/A
Documentation Required
- Review the member's benefit plan, summary plan description, or contract to determine coverage, exclusions, and limitations.
- Check applicable state regulations for restrictions or additional requirements.
- Documentation that Emergency Ground Ambulance Transport criteria in Section I are met.
- Clinical documentation of critical condition and/or unstable vital signs, respiratory status, or cardiac status and documentation supporting one of the listed emergent conditions.
Key Coverage Criteria
- The use of emergency ground ambulance services is consideredmedically necessarywhenallthe following criteria are met:
- The ambulance must have the necessary equipment and supplies to address the needs of the individual;and
- The individual’s condition must be such that any form of transportation other than by ambulance would be medically contraindicated;and
- Either of the following circumstances exists:Transportation from the scene of a life-threatening accident or emergency to thenearest*hospital or physician’s office with appropriate facilities for treatment of an individual’s illness or injury is required;orTransportation to or from one hospital or medical facility to another hospital or medical facility, skilled nursing facility, or free-standing dialysis center in order to obtain emergent medically necessary diagnostic or therapeutic services i [...]
- Transportation from the scene of a life-threatening accident or emergency to thenearest*hospital or physician’s office with appropriate facilities for treatment of an individual’s illness or injury is required;or
- Transportation to or from one hospital or medical facility to another hospital or medical facility, skilled nursing facility, or free-standing dialysis center in order to obtain emergent medically necessary diagnostic or therapeutic services is required (for example magnetic resonance imaging, computed tomography scan, acute interventional cardiology, intensive care unit [ICU] services [including neonatal ICU], Cobalt therapy, etc.) provided such services are unavailable at the facility where th [...]
7 Active Policies
ANTHEM-CG-ANC-05, CG-ANC-05 Ambulance Services: Ground; Emergent
ANTHEM-CG-ANC-04, CG-ANC-04 Ambulance Services: Air and Water
ADM1001.005, Ambulance and Transport Services
BCBSIL-MED201.058, Ambulance and Transport Services
BCBSMT-MED201.058, Ambulance and Transport Services
Related Codes
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